Pneumococcal Vaccine


Article Author:
Stela Tereziu


Article Editor:
David Minter


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/22/2019 6:46:17 PM

Indications

The advent of pneumococcal vaccines has proven to be a significant advancement in the treatment and prevention of a widespread and sometimes deadly disease process.  [1][2][3][4]

Pneumococcal conjugate vaccine (PCV13) is recommended differently depending on patient population. In patients 6 weeks old through 6 years of age, PCV13 is recommended for active immunization for the prevention of diseases considered invasive and caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F. It is also recommended for the prevention and active immunization of otitis media caused by S. pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F. In patients aged 7 to 17 years old, it is recommended for prevention of invasive disease in subtypes mentioned above. In patients 18 years old and older, it is indicated for active immunization, and prevention of pneumococcal pneumonia, caused by the subtypes of S. pneumoniae, as listed above.

Another pneumococcal vaccine, PPSV23, is indicated in the United States for all adults 65 years of age and older, as well as younger patients with conditions that increase the risk for developing pneumococcal pneumonia or invasive pneumococcal disease. Conditions in which PPSV23 would be indicated in patients younger than 65 years of age are as follows: chronic heart disease excluding hypertension, chronic lung disease including asthma, diabetes mellitus, cerebrospinal fluid leak, cochlear implant, alcoholism, chronic liver disease, cigarette smoking, hemoglobinopathy (including sickle cell disease), congenital/acquired asplenia, congenital/acquired immunodeficiency, human immunodeficiency virus infection, chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, patients receiving immunosuppressive medications (anti-tumor necrosis factor [TNF], chemotherapy agents), solid organ transplant, and multiple myeloma. It is also recommended that all patients who received PPSV23 before the age of 65 years be revaccinated at age 65 unless the vaccine is given less than 10 years prior to patient turning 65 years old, in which case patients should be revaccinated 10 years following the first dose. It is also recommended that patients with functional or anatomic asplenia or immunocompromised individuals receive repeat doses of the vaccination every 10 years after the first dose.

PCV13 and PPSV23 Together

While both vaccine types are proven to stimulate long-lasting antibodies in immunocompromised adults, conjugate vaccines have been proven to provide some additional benefits. Benefits of polysaccharide conjugate vaccine over traditional polysaccharide vaccine include that conjugate vaccines stimulate the production of these antibodies in infants and toddlers, as opposed to only healthy adults, as seen with polysaccharide vaccines. Conjugate vaccines have also been found to stimulate mucosal immunity, which decreases colonization, as well as have been proven to provide herd immunity and prime the patient immunologically, for an enhanced host response, unlike traditionally polysaccharide vaccines.

The ACIP recommends that both vaccinations be given to patients with any of the following: Cerebrospinal fluid leak, cochlear implant, anatomic/functional asplenia, and immunocompromising conditions listed above.

Mechanism of Action

Both vaccines promote active immunization against the serotypes of the conjugate and capsular polysaccharides contained in the formulation of the vaccine. Immunity develops approximately 2 to 3 weeks after vaccination and lasts for 5 years. In children and elderly, re-immunization may be needed sooner.

PCV13

PCV 13 actively immunizes against invasive disease caused by S. pneumoniae capsular serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F. All of the serotypes are individually conjugated to a CRM197 protein.

PPSV 23

PPSV 23 contains 23 capsular polysaccharides types of S. pneumoniae that represent at least 85% to 90% of pneumococcal disease isolates in the United States. It has shown a 50% to 80% efficacy in preventing invasive pneumococcal disease in adults.

S. pneumoniae serotypes: 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F

Administration

PCV13

Single 0.5 ml injection, intramuscularly only. In patients 6 weeks through 5 years of age, it is administered as part of a 4-dose immunization series, administered as 0.5 mg intramuscular injections given at 2, 4, 6, and 12 to 15 months of age. In all patients six years of age and older, it is administered at a single 0.5 ml intramuscular injection.[5][6][7][8]

PPSV23

Single 0.5 ml injection, intramuscular/subcutaneously

PCV13 and PPSV23 Together

Patients of any age for whom it is recommended receive both vaccinations and should receive them as follows:

If the patient has had no prior vaccination with either vaccine, the patient should receive a single dose of PCV13. Eight weeks or more following this dose, PPSV23 should be given. PPSV23 should be given no sooner than 8 weeks following administration of PVC13.

If the patient has received PPSV23 in the past, a single dose of PCV13 should be given 1 year after the administration of PPSV23. PVC13 should be given no sooner than 1 year following that administration of PPSV23.

Adverse Effects

The following adverse effects have been reported in different age groups. The list includes the most common side effects. However, it is not limited to all of the side effects. 

PCV13

Infants and Toddlers (most commonly reported reactions greater than 5%)

  • Irritability (greater than 70%)
  • Injection site tenderness (greater than50%)
  • Decreased appetite (greater than40%)
  • Decreased sleep (greater than 40%)
  • Increased sleep (greater than 40%)
  • Fever (greater than 20%)
  • Injection site redness ( greater than20%)
  • Injection site swelling (greater than 20%)

Children Aged 5 to 17 Years Old

  • Injection site tenderness (greater than 80%)
  • Injection site redness (greater than 30%)
  • Injection site swelling (greater than 30%)
  • Irritability (greater than 20%)
  • Decreased appetite (greater than 20%)
  • Increased sleep (greater than 20%)
  • Fever (greater than 5%)
  • Decreased sleep (greater than 5%)

Adults 18 Years and Older

  • Pain at injection site (greater than 50%)
  • Fatigue (greater than 30%)
  • Headache (greater than 20%)
  • Muscle pain (greater than 20%)
  • Joint pain (greater than 10%)
  • Decreased appetite (greater than 10%)
  • Injection site redness (greater than 10%)
  • Injection site swelling (greater than 10%)
  • Limitation of arm movement (greater than 10%)
  • Vomiting (greater than 5%)
  • Fever (greater than 5%)
  • Chills (greater than 5%)
  • Rash (greater than 5%)

PPSV23

Common Reactions to PPSV23 (greater than 10% of patients)

  • Injection site pain/soreness/tenderness (60%)
  • Injection site induration/swelling (20.3%)
  • Headache (17.6%)
  • Injection site erythema (16.4%)
  • Fatigue/weakness (13.2%)
  • Myalgia (11.9%)

Concomitant administration of PPSV23 and live zoster vaccine showed a reduced immune response to live zoster vaccine. It is recommended that they be administered at least 4 weeks apart.

PCV13

Studies done on animals have not shown fetal adverse effects or increase risk to the fetus. It is unknown if the vaccine is excreted with breast milk. Caution should be exercised when administering this vaccine to breastfeeding women.

PPSV23

Animal reproduction studies have not been conducted. However, PPSV 23 is an inactivated vaccine, and studies of other inactivated vaccines have not shown to cause increased risk to the fetus. It is unknown if the vaccine is excreted with breast milk. Caution should be exercised when administering this vaccine to breastfeeding women.

Contraindications

PCV13 and PPSV23 contraindications include severe allergic or anaphylactic reaction to any component of the formulation of the vaccine or any diphtheria toxoid-containing vaccine. Pregnancy is not a contraindication to vaccination. Pregnant women at high risk of infection are recommended to receive vaccination.

Monitoring

For the first 15 minutes after administration, patients should be monitored for an allergic reaction like anaphylaxis and syncope.

Toxicity

There is no overdose risk with the administration of the vaccine.

Enhancing Healthcare Team Outcomes

The pneumococcal vaccine is effective and can help reduce the risk of infection. The primary care provider, nurse practitioner, pharmacist and other healthcare workers should educate patients on the benefits of the pneumococcal vaccine. Over the years, the vaccine has proven to be safe and effective.[9]


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Pneumococcal Vaccine - Questions

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A mother tells you that she has never heard of the pneumococcal conjugate vaccine that you are recommending for her infant. Which of the following statements about this vaccine is true?



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Which of the following vaccines is frequently recommended for individuals 65 years of age and greater?



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What percentage of adults who are between the ages 19 to 64 receive the pneumococcus vaccine?



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Which population does not need the pneumococcal vaccine?



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Which of the following is not an indication for pneumococcal vaccination?



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A 63-year-old male presents for a routine annual visit. He does not have any major medical conditions, and a daily, low-dose aspirin is his only medication. He has a 26 pack-year smoking history and quit smoking 15 years ago. His vital signs and exam are within normal limits. He enquires about age appropriate vaccinations, specifically to prevent pneumonia. He tells you that he read a newspaper about the new 13 valent pneumococcal vaccine (PCV 13). Which of the following is the correct recommendation?



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A 35-year-old female with cochlear implants and diabetes mellitus receives the PCV13 vaccine instead of the PPSV23 vaccine. Which serotype of Streptococcus pneumoniae is she not covered for due to incorrect vaccination administration?



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What are the current recommendations by the CDC for pregnant women receiving PCV13 pneumococcal vaccinations?



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What is the most common adverse effect seen with pneumococcal vaccination in infants and toddlers?



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Pneumococcal Vaccine - References

References

Marijam A,Olbrecht J,Ozakay A,Eken V,Meszaros K, Cost-Effectiveness Comparison of Pneumococcal Conjugate Vaccines in Turkish Children. Value in health regional issues. 2019 Feb 15;     [PubMed]
Huang J,Luo S,Huang M,Zhang T,Min Z,Liu C,Zhang Q,Yang J,Min X, Protection against fatal pneumonia through mucosal and subcutaneous immunization with the pneumococcal SP0148 protein. Microbial pathogenesis. 2019 Feb 14;     [PubMed]
Wiese AD,Griffin MR,Grijalva CG, Impact of pneumococcal conjugate vaccines on hospitalizations for pneumonia in the United States. Expert review of vaccines. 2019 Feb 13;     [PubMed]
Ozlu T,Bulbul Y,Aydin D,Tatar D,Kuyucu T,Erboy F,Koseoglu HI,Anar C,Sunnetcioglu A,Gulhan PY,Sahin U,Ekici A,Duru S,Ulasli SS,Kurtipek E,Gunay S, Immunization status in chronic obstructive pulmonary disease: A multicenter study from Turkey. Annals of thoracic medicine. 2019 Jan-Mar;     [PubMed]
Lewnard JA,Hanage WP, Making sense of differences in pneumococcal serotype replacement. The Lancet. Infectious diseases. 2019 Jan 29;     [PubMed]
Papadatou I,Tzovara I,Licciardi PV, The Role of Serotype-Specific Immunological Memory in Pneumococcal Vaccination: Current Knowledge and Future Prospects. Vaccines. 2019 Jan 29;     [PubMed]
Vadlamudi NK,Parhar K,Altre Malana KL,Kang A,Marra F, Immunogenicity and safety of the 13-valent pneumococcal conjugate vaccine compared to 23-valent pneumococcal polysaccharide in immunocompetent adults: A systematic review and meta-analysis. Vaccine. 2019 Feb 14;     [PubMed]
Kuronuma K,Takahashi H, Immunogenicity of pneumococcal vaccines in comorbid autoimmune and chronic respiratory diseases. Human vaccines     [PubMed]
Zhou X,de Luise C,Gaffney M,Burt CW,Scott DA,Gatto N,Center KJ, National impact of 13-valent pneumococcal conjugate vaccine on ambulatory care visits for otitis media in children under 5 years in the United States. International journal of pediatric otorhinolaryngology. 2019 Jan 19;     [PubMed]

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